Posterior tibial tendon dysfunction (PTTD), is one of the major causes of acquired flatfoot in adults. It is more common in males with the peak incidence occurring at 51 years of age. The onset of PTTD may be slow and progressive or traumatic.  An traumatic onset is typically linked to some form of trauma. PTTD is seldom seen in children and increases in frequency with age.
The classic PTTD foot has the following signs, loss of medial arch, swelling of the medial ankle, loss of the ability to resist force to abduct or push the foot out from the midline of the body, pain on the medial ankle with weight bearing, inability to raise up on the toes without pain.

In advanced cases of PTTD, in addition to the pain of the tendon itself, pain will also be noted at the sinus tarsi.  There have been many proposed explanations for PTTD over the years  since this condition was first described.  The most contemporary explanation refers to an area of hypovascularity (limited blood flow) in the tendon just below the ankle.  Tendon derives most of its' nutritional support from synovial fluid produced by the outer lining of the tendon.  Extremely small blood vessels also permeate the tendon sheath to reach tendon.  This makes all tendon notoriously slow to heal.  In the case of the posterior tibial tendon, this problem is exacerbated by a distinct area of poor blood flow (hypovascularity). 
Tendon is also most susceptible to fatigue and failure at an area where the tendon changes direction.   The tendon then takes a dramatic turn towards the arch of the foot.  If the tendon is put into a situation where significant load is applied to the foot, the tendon responds by pulling up as the load of the body (in addition to gravity) pushes down.  At the location where the tendon changes course, the tibia acts as a wedge and may apply enough force to actually damage or rupture the tendon.
Additional contributing factor to the onset of PTTD may include hypertension, diabetes, peripheral neuropathy, smoking or arthritis.  The progression of PTTD may result in tendonitis, partial tears of the tendon or complete tendon rupture. 
This condition requires the use of custom orthotics to support the foot, a Podiatrist will be able to assess this foot type and provide appropriate orthotics.










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Page last updated 14 October, 2007